INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 24, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, MVP Recovery, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure that all counselors met the experiential qualifications for the position in two of two applicable personnel records reviewed.
Employee #2 was hired as a counselor on January 23, 2023 and was still in the position at the time of the inspection. The employee had a qualifying bachelor ' s degree; however, the employee did not have the required 1 year of clinical experience prior to hire. The employee only had 5 months of documented clinical experience upon hire.
Employee #3 was hired as a counselor on July 25, 2022 and was still in the position at the time of inspection. The employee had a qualifying bachelor ' s degree; however, the employee did not have the required 1 year of clinical experience prior to hire. The employee did not have any documented clinical experience upon hire.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Director has created hiring forms that will be used during the interviewing process to ensure that a new hire is identified as counselor assistant or counselor prior to hire. The forms have been created with the detail included in the staffing regulation to classify staff accordingly. The director will complete this form for each new hire and it will be reviewed by the regional director or CEO prior to hiring staff. The hiring forms will be signed off by director, and supervisor prior to HR onboarding is started. The hiring form will be keep in employee's personnel file and will be reviewed monthly in supervision to ensure all requirements of position for employee will be met. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the project failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in four of six applicable client records reviewed.
Client #1 was admitted on January 25, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on February 23, 2023 and the first update was due no later than April 23, 2023; however, the update was not completed until May 9, 2023.
Client #3 was admitted on November 3, 2022 and was active at the time of inspection. A treatment plan update was completed on January 26, 2023 and the next update was due no later than March 26, 2023; however, the update was not completed until April 26, 2023.
Client #4 was admitted on February 2, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on February 16, 2023 and the first update was due no later than April 16, 2023; however, the update was not completed until May 9, 2023.
Client #5 was admitted on December 29, 2022 and was discharged on April 4, 2023. The individual treatment and rehabilitation plan was completed on January 18, 2023 and the first update was due no later than March 18, 2023; however, the update was not completed prior to client's discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff education will be provided during department staff meeting on 6/9/23 regarding the Treatment plan update policy. Director will provide an overview of the policy for staff, provide a written copy to the staff, and staff will sign off on the education provided once all questions are answered. During this staff meeting and ongoing supervision director will provide tips on tracking treatment plan time frames to ensure compliance.
Staff will also be educated on the process of reviewing the treatment plan at the beginning of each session with client to both measure progress on goals and also to ensure that compliance with dates of updates are kept.
Director will conduct on going chart audits of 3 charts per staff member per week. The director will provide each staff member with the results of the chart audits with a date that corrections are to be completed by. The chart audit form contains many reviews for compliance reasons, but specifically includes treatment plan dates as apart of the audit.
Director will review each staff members chart audits in weekly supervision.
Director will be responsible to monitor and ensure compliance is kept and out of date treatment plan updates do not reoccur. |